Facility Evaluation Report

Licensing Program Analyst (LPA) Talwinder Bains arrived on 05/01/25 to conduct the annual inspection. LPA met with staff Tonya Miles and explained the purpose of today's visit. LPA was notified by staff that administrator was not available today to assist with today's visit. LPA Cheyenne Ratajczak and Licensing Program Manager (LPM), Laura Munoz came after short while to assist with today's visit. Administrator Irene Nepomuceno arrived at 11:32 AM. Following issues were also observed during annual inspection;

LPA observed the facility to have a door stopper propping open the fire door in the hallway.

LPA found out from staff interview that resident, R1 was sent out to hospital due to right hip fracture on 03/24/25 but facility did not report this incident to Department per Reporting Requirements.

Deficiencies cited as indicated on LIC809-D, civil penalties assessed.

Exit interview and a copy of the report ,LIC809G and appeal rights left at the facility.